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nut" Gg g/a�ao� SAN JOAQUIN COUNTY Ito <br /> 2 ti ENVIRONMENTAL HEALTH DEPARTMENT <br /> �• 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> cq. :-..•;P el e:(209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> •r��r7 Y/�Jyn� VECTOR CONTROL INSPECTION FORM <br /> POULTRY RANCH DBA INS ECTI NDATE <br /> Structure Operation G 1 � <br /> ❑ ❑ 1. Well Construction PREMISE ADDRESS RE-INSPECTION DATE <br /> ❑ ❑ 2. Cross-Connection 1115 E. g-TOW C& 19, 3 <br /> Structure Operation Manure Management OWNER/OPERATOR PHONE <br /> ❑ ❑ 3. Spreading and Disking <br /> ❑ ❑ 4. Concrete Tanks INSPECTION TYPE PROGRAM ELEMENT RECORD ID <br /> ❑ ❑ 5. Lagooning O 14 C1 ce()0.5 60-d n <br /> ❑ ❑ 6. Composting The items below represent code violations and must be corrected: <br /> Structure Operation Bird Disposal /� <br /> ❑ ❑ 7. Burying with 2"of Cover A <br /> ❑ ❑ 8. Approved Concrete Tank <br /> ❑ ❑ 9. Removal from Premises1.2;9112,3Flit- <br /> Structure Operation Vector Control <br /> ❑ ❑ 10. Domestic FI k <br /> 11. Fannia FI <br /> ❑ ❑ 12. Larvae .4 _ �j <br /> ❑ ❑ 13. Pupae <br /> ❑ ❑ 14. Adult _ TM VSj A, - P+• <br /> ❑ ❑ 15. Light Population <br /> ❑ ❑ 16. Moderate Population tLt k tiount,5. A <br /> ❑ 17. Heavy Population <br /> Structure Operation Feeding/Water Q t <br /> ❑ ❑ 18. Water Troughs <br /> ❑ ❑ 19. Cups or Bowls \/k C <br /> 20. Food Storage <br /> Structure Operation Houses <br /> ❑ ❑ 21. Floors <br /> ❑ ❑ 22. Walls/Ceilings <br /> ❑ ❑ 23. Cleaning Frequency <br /> KENNEL C, _ - L <br /> Structure Operation Water Well <br /> ❑ ❑ 1. Well Construction _ <br /> ❑ 2. Cross Connection <br /> Structure Operation Floors <br /> ❑ ❑ 3. Properly Graded to Sewer <br /> ❑ ❑ 4. Drain ; - 5 _ - <br /> ❑ ❑ 5. Smooth/Cleanable <br /> ❑ ❑ B. Covin <br /> 7. Cleaning Frequency <br /> Structure Operation Walls <br /> ❑ ❑ 8. Smooth/Cleanable <br /> ❑ ❑ 9. Cleaning Frequency <br /> Structure Operation Cages <br /> ❑ ❑ 10. Condition <br /> ❑ 11. Sanitation <br /> Structure Operation Food <br /> ❑ ❑ 12. Storage <br /> 13. InsecWermin <br /> Structure Operation Animal Disposal <br /> ❑ ❑ 1 14. Removal from Premises <br /> ❑ ❑ 1 15. Other <br /> Structure Operation Sewage Disposal <br /> ❑ ❑ 16. Septic System <br /> ❑ ❑ 17. Sewer <br /> Structure Operation Rabies Vaccination RECEIVED BY �1 INSPECTOR <br /> -7 i <br /> ❑ ❑ 18. Certificate on Premises i L <br /> LSC <br /> VECTOR CONTROL INSPECTION FORM . <br /> EHD 40-06 4/6/12 <br /> Page_of <br />